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RAILROAD ACCIDENT REPORT 

HAZARDOUS MATERIALS ACCIDENT 

IN THE RAILROAD YARD OF THE 

NORFOLK AND WESTERN RAILWAY AT 

DECATUR, ILLINOIS 

JULY 19, 1974 




NATIONAL TRANSPORTATION SAFETY BOARD 
Washington, D.C. 20594 
REPORT NUMBER: NTSB-RAR-75-4 



OTZLO -ff- f/^ua\ 




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SS-R-31 

RAILROAD ACCIDENT REPORT 

HAZARDOUS MATERIALS ACCIDENT 

IN THE RAILROAD YARD OF THE 
NORFOLK AND WESTERN RAILWAY AT 
DECATUR, ILLINOIS 
JULY 19, 1974 
ADOPTED: APRIL 10, 1975 




NATIONAL TRANSPORTATION SAFETY BOARD 
Washington, D. C. 20594 
REPORT NUMBER: NTSB-RAR-75-4 



TECHNICAL REPORT STANDARD TITLE PAGE 



1 . Report No. 
NTSB-RAR-75-4 



2. Government Accession No. 



k. Title and Subtitle Railroad Accident Report — 
Hazardous Materials Accident in the Railroad Yard of the 
Norfolk and Western Railway at Decatur, Illinois, July 

19, 1974. 

7. Author(s) 



3. Recipient 's Catalog No. 



5. Report Date 

April 10, 1975 



6. Performing Organization 
Code 



8. Performing Organization 
Report No. 



9. Performing Organization Name and Address 
Bureau of Surface Transportation Safety 
National Transportation Safety Board 
Washington, D. C. 20594 



10. Work Unit No. 
1381-A 



11. Contract or Grant No. 



12. Sponsoring Agency Name and Address 

NATIONAL TRANSPORTATION SAFETY BOARD 
Washington, D. C. 20594 



13.Type of Report and 
Period Covered 

Railroad Accident Report 
July 19, 1974 



1 4. Sponsor i ng Agency Code 



1 5. Supplementary Notes 

This report contains Railroad Safety Recommendations R-75-18 thru R-75-22 



16. Abstract gATX 41623 and four other tank cars loaded with isobutane gas were un- 
coupled at the west end of Decatur Yard by a switching crew and allowed to free roll 
eastward on yard track 11. The car impacted an empty boxcar, and its coupler over- 
rode the tank car coupler and punctured the tank. Isobutane escaped and vaporized 
for 8 to 10 minutes before it exploded. The yard, surrounding residences, and com- 
mercial facilities were damaged extensively by fire and shock waves. Seven eirployees 
died from burns, and 33 employees were injured. Three hundred sixteen persons out- 
side the rail yard were also injured as a result of the explosion. Property damage 
was estimated at $18 million. 

The National Transportation Safety Board determines that the probable cause of 
the accident was the overspeed inpact between the heavy cut of tank cars and the un 
coupled light boxcar, which resulted from the release of the tank cars at a higher- 
than -acceptable switching speed. The lack of written guidelines to assist the 
switchm,-in in determining the proper switching speed contributed to the accident. The 
crewmembers' lack of understanding of the risks involved in switching hazardous 
materials also was a contributing factor. 

Recommendations were made regarding tank head shields and couplers, employee 
training, hazardous materials accident data reporting, and regulations to limit 
losses in hazardous materials accidents. 



18. Distribution Statement 
This document is available to 
the public through the Nation 
al Technical Information 
Service, Springfield, Vir 
ginia 22151. 



17. Key Words 

Hazardous Materials, Isobutane, Head Shields, F-type 
Coupler, E-type Top and Bottom Shelf Coupler, Flat 
Switching, Overspeed Iiiqjact, Rolling Tests, Tank Car 
Head, Head Puncture, Overriding Coupler, Open Air 
Detonation, Explosion 



19. Security Classification 
(of this report) 
UNCLASSIFIED 



20.Security Classification 
(of this page) 
UNCLASSIFIED 



21 .No. of Pages 

33 



22. Price 



NTSB Form 1765.2 (11/70) 



ii 



FOREWORD 



The accident described in this report has been designated a major 
accident by the National Transportation Safety Board under the criteria 
established in the Safety Board regulations. 

This report is based on facts obtained from an investigation con- 
ducted by the Safety Board in cooperation with the Federal Railroad Ad- 
ministration. The conclusions, the determination of probable cause, and 
the recommendations are those of the Safety Board . 



TABLE OF CONTENTS 

Page 

SYNOPSIS ...... p .... o ... o , . . . 1 

FACTS ...... ...... 1 

Accident 1 

Accident Site and Method of Operation „ 2 

Yard Location and Site 2 

Annex Location 4 

Method of Operation 4 

Training and Experience 5 

Impact and Explosion 5 

Damages ......... 7 

Injuries 9 

Equipment 9 

GATX 41623 9 

N&W 49203 9 

Other Cars of Hazardous Materials 9 

Emergency and Rescue ........... 11 

N&W Operating Controls 11 

Tests 11 

Regulatory Activity ........... ... . 12 

ANALYSIS . 13 

The Accident ..... 13 

Losses Attributable to Hazardous Materials .... 13 

The Dormitory Location 14 

Postaccident Emergency Plan 14 

Puncture of Tank Heads in Switching Accidents ....... 14 

Damage and Casualty Reports .... 15 

CONCLUSIONS . ....... 16 

PROBABLE CAUSE 17 

RECOMMENDATIONS ................ 17 

APPENDICES : 

Appendix A - Cut Slip for Assignment No. 1 ........ . 19 

Appendix B - General Notice ................ 20 

Appendix C - Notice of Proposed Rule Making HM-120-Switching 

of Placarded Dangerous Cars .......... 21 

Appendix D - State of Illinois Commerce Commission Interim 

General Order 200 ............... 22 

Appendix E - NTSB Interim Safety Recommendations R- 74-2 9 

and 30 .................... 26 

Appendix F - FRA Emergency Order No. 5 .......... . 30 



SS-R-31 

NATIONAL TRANSPORTATION SAFETY BOARD 
WASHINGTON, D. C. 20594 

RAILROAD ACCIDENT REPORT 

Adopted; April 10. 1975 

Hazardous Materials Accident 

in the Railroad Yard of the 

Norfolk and Western Railway at 

Decatur, Illinois 

July 19, 1974 

SYNOPSIS 

On July 19, 1974, a switching crew in the Decatur Yard of the 
Norfolk and Western Railway at Decatur, Illinois, switched five jumbo 
tank cars loaded with isobutane onto yard track 11 in a free=rolling, un- 
controlled operation. The five tank cars rolled eastward on track 11 and 
inpacted an enpty boxcar standing free and uncoupled. On impact, the 
west coupler of the boxcar overrode the east coupler of the first tank 
car and penetrated the tank car. 

Isobutane spilled from the 22-inch by 26-inch puncture for 8 to 10 
minutes and vaporized. At 5:03 a.m., an undetermined source ignited the 
vaporized isobutane and it exploded. The shock wave was felt 40 miles 
from the rail yard; more than 700 homes were damaged — some so badly 
that they were declared uninhabitable. Railroad equipment on neighboring 
tracks was damaged extensively by the explosion and subsequent fire. 
Damage was estimated at $18 million. 

Numerous injuries were reported by persons outside the rail yard. 
Seven railroad en^jloyees who were near the explosion were killed. 

The National Transportation Safety Board determines that the prob- 
able cause of the accident was the overspeed impact between the heavy cut 
of tank cars and the uncoupled light boxcar, which resulted from the re- 
lease of the tank cars at a higher -than -acceptable switching speed. The 
lack of written guidelines to assist the switchman in determining the 
proper switching speed contributed to the accident. The crewmembers' 
lack of understanding of the risks involved in switching hazardous mate^- 
rials also was a contributing factor. 

FACTS 

Accident 

The tank cars involved in the accident were part of an 18-car draft 
which was interchanged to the Norfolk and Western Railway (N&W) at 



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Decatur. An interchange inspection was conducted by N&W car inspectors, 
and they determined that all cars were free of defects and acceptable for 
interchange. (See Appendix A.) 

The draft of cars, including the engine, was assigned for switching 
to east Decatur Yard assignment No. 1, which worked from 11:45 p.m., July 
18 to 7:45 a.m., July 19. Assignment No, 1 moved the cars from track 5 
to the lead track on the west end of the yard and began the switching. 

During the switching of the draft, the five-car cut of loaded tank 
cars was routed toward track 12 instead of track 11. Then two cars were 
switched onto track 10, and N&W boxcar 49203 was switched onto track 11. 
The car was eiqjty. After that move, the switching crew pulled the five 
tank cars and two boxcars back to the middle lead, from which point the 
two boxcars were switched onto track 4. The five-car cut of tank cars 
was uncoupled on the lead track about 20 car lengths west of the switch 
to track 11 at a speed, according to the crew, of 3.5 to 4 mph (or no 
faster than a brisk walk) . 

When the five tank cars were switched correctly toward track 11, no 
member of the crew took exception to the speed at which the cars were 
moving as they entered track 11. However, a yard clerk testified that he 
believed that the cars were moving a little too fast, and he suggested 
to a crewmember that a handbrake be applied to that cut of cars. 

Immediately after the cut of tank cars was released onto track 11, 
the crew proceeded to switch the cars on tracks 10 and 12. During their 
work, the crew noticed a dense gray cloud in the vicinity of the dormi- 
tory. As the crew observed the cloud, it exploded. All crewmembers ran 
toward the East Decatur Tower. No member of the crew recalled hearing 
any abnormal in^acts or sounds before the explosion, but the yard clerk 
reported hearing an abnormally high impact in the vicinity of the dormi- 
tory. An employee in the dormitory also reported being awakened by loud 
switching in^jact noises in the area before the explosion. 

The weather was clear and a northwest breeze was blowing. 

Accident Site and Method of Operation 

Yard Location and Site — N&W's Decatur yard is located on the east 
side of the city. A service road, which runs east and west, divides the 
yard into an eastbound portion and a westbound portion. The general yard 
offices and East Decatur Tower are located at the west end of the westbound 
yard. Brush tower is located at the east end of the westbound yard. (See 
Figure 1.) A yardmaster is on duty in each of the towers 24 hours a day. 

Each end of the yard is elevated so that cars which are uncoupled at 
either end will maintain their cutoff speed into the basin unless they are 



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braked to a stop or coupled with other cars on the same track. Track 11 
in the westbound yard has descending grades eastward of o35 percent at the 
west switch for about 120 feet, .47 percent for about 75 feet, .22 per- 
cent for about 2,100 feet, and a percent grade in the basin. There are 
no mechanical retarding devices. 

Annex Location -- The Annex building, which consisted of a small 
restaurant, locker space, and sleeping facilities, was located about mid- 
way between East Decatur Tower and Brush tower adjacent to the service 
road. The building was a dormitory for crews whose home terminals were 
not Decatur. 

Method of Operation — The responsibility for the operation of the 
yard was assigned to an assistant superintendent who was assisted by two 
trainmasters and a general yardmaster. The yardmasters assigned the work 
to the switching crews. Each switching crew was composed of a yard fore- 
man, two switchmen, an engineer, and occasionally a fireman or engineer 
trainee. 

Cars received at Decatur Yard were inspected by qualified car in- 
spectors. After the inspection, the results were reported to the yard- 
master who assigned the cars to a crew for switching. 

Cars were switched at each end of the yard in a typical flat-switch- 
ing manner. The locomotive accelerated the cars to the appropriate 
speed, then a switchman (pin puller) uncoupled the cars and as the loco- 
motive slowed, they rolled freely to a stop. The appropriate routes were 
set up by the other switchman (field man) who may control the speed of 
the free-rolling cars by means of handbrakes. Based on their past ex- 
perience, the crewmembers determined the proper switching speed. There 
were no written guidelines on which the switchmen could base their deter- 
minations. The yard foreman had the primary responsibility for switching 
the cars at safe speeds. 

The switchmen were concerned with releasing a car at a speed fast 
enough to move it onto the assigned track so that it would not block the 
switching lead. Switchmen stated that they were not responsible for the 
speed of the car after it left the lead, and that often, they did not 
know how far the cars would roll before impacting other cars on the track. 
No special switching precautions were taken for hazardous materials plac- 
arded "DANGEROUS." Switchmen interviewed did not have a clear understand- 
ing of the proper manner in which to handle cars of Class A explosives. 

Operational procedures were established and regulated by general 
orders, general notices, bulletins, and operating rules. Carrier and 
regulatory witnesses testified that they assumed that conformance with 
safety rules will assure safe transportation of hazardous materials. 
They also testified that they knew of no rules that were not observed 
which contributed to the accident. 



- 5 - 



In its approach to safety regulations governing hazardous materials, 
the Federal Railroad Administration (FRA) atteir^ts to relate the degree 
of protection afforded specific commodities to the degree of severity of 
accidents. No atten^t is made to relate the amount of material present 
in an accident to the severity of the accident likely to occur. 

Training and Experience 

The car inspectors, yardmasters, the clerk, and switchmen were 
trained on the job. The engineer had been promoted after 3 years as a 
fireman and had been engineer on a locomotive for about 15 months. The 
engineer was not trained under the current training program, which in- 
cludes classroom instruction and written and oral tests. 

The traincrew's experience varied from 1 1/2 years for the yard fore- 
man to 5 months for one of the switchmen. The yardmaster had about 5 
years' experience, and the yard clerk had about 6 years. One car in- 
spector had 20 years' experience, while the other one had only 6 months. 
Their training and experience did not include instructions regarding the 
risks of transporting dangerous articles. Information relating to hand- 
ling of hazardous materials was obtained verbally or from posted material. 
Supervisors did not insure that employees received, read, or understood 
the posted material. 

There was no procedure for disseminating new information about the 
risks of switching hazardous materials, except the posting of information 
furnished by the Bureau of Explosives. Safety information acquired from 
a similar switching accident at East St. Louis, Illinois, in January 1972, 
was not made available to the supervisors or switchmen. 

Impact and Explosion 

Switchmen reportedly released the cut of tank cars at a speed of 3,5 
to 4 iqjh. The five tank cars impacted empty boxcar N&W 49203, which had 
stopped in track 11 after traveling about 2,700 feet. The couplers between 
GATX tank car 41623 and N&W 49203 met slightly off center vertically so 
that the boxcar coupler was deflected downward with sufficient force to 
break the carrier iron and to bend permanently the shank of the boxcar 
coupler. The boxcar coupler then overrode the tank car coupler and punc- 
tured the head of the tank car at the 5-o 'clock position. The boxcar 
lifted off its truck and canted northward and was pushed about 63.5 feet 
without striking the cars on track 11 ahead of ito 

Liquid isobutane spilled from the 22-inch by 26-inch puncture at the 
rate of about 5,000 gallons per minute. The liquid vaporized, and a 
northwest wind spread the cloud southeastward for about 8 to 10 minutes. 
The cloud was then ignited by an unknown source and exploded violently. 
(See Figure 2.) 



- 6 - 




- 7 - 



At Decatur the open-air explosion of the gas-air mixture is sub= 
stantiated by two significant facts: (1) All cars containing commodities 
which could explode were accounted for after the explosion; (2) there 
were no craters after the explosion. Such an explosion would have re- 
quired a carload of explosive material and would have caused a large 
crater . 

Damages — Damages resulted primarily from fire and concussion. 
When the gas cloud ignited, the flash scorched a large portion of both 
yards and ignited numerous cars and their lading. Fire damage was con- 
fined to the yards. 

Fire and concussion demolished 283 freight cars and damaged to a 
lesser extent 312 others. The dormitory was destroyed by fire and con- 
cussion. 

Concussion damage was evident in all directions from the site of the 
explosion. Most structural damage was within a mile of the explosion; 
however, windows were broken more than 3 miles from the explosion. The 
most extensive structural damages occurred on the north side of the yard. 
Industrial facilities, residences, and mobile homes were damaged. 

About 700 residences were damaged by concussion, 67 of which authori- 
ties declared uninhabitable; damage ranged from broken windows to col- 
lapsed roofs and walls. Many furnishings were damaged by flying glass 
and other debris. Lakeview High School, which was adjacent to the east- 
bound yard, was one of the most severely damaged buildings. An unfinished 
addition to the school was demolished. Ten other schools were also 
damaged. (See Figures 3 and 4.) Thirty-one commercial establishments 
reported damages to structures and contents. 

Total estimated damages were as follows: 

Railroad 

Cars $ 3.7 million 

Lading 3.2 million 

Other Costs 1.0 million 

Commercial 4.9 million 

Residential 2.5 million 

City, including emergency 
services 3.1 million 



$18.4 million 




..jmst^^is^^iiamjam^- 



Figure 3. Typical Damage, Residential Area 
Decatur, Illinois 




Figure 4. Damage to Lake View School, Decatur, Illinois, 



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Injuries — Most of the reported injuries were burns , lacerations , 
contusions, or a combination of these. Forty N&W employees were injured, 
seven of whom died from burns . Most of the injured en^loyees were either 
in the dormitory or adjacent to it. All of those who were fatally burned 
were outside of the dormitory. 

Three hundred sixteen nonrailroad persons suffered burns, lacerations, 
contusions, anxiety, eye injuries, and concussions. 

Equipment 

GATX 41623 — GATX 41623 was a 33,500 gallon, DOT Specification 
114A340W stubsill tank car built by General American Transportation Cor- 
poration in September 1971. It was equipped with 100- ton. Barber S2C 
trucks with roller bearings and 36-inch steel wheels. It had truckmounted 
brakes with an 8%-inch cylinder and ABEX H-I-A shoes. The handbrake was 
a Miner 6600L. The tank car was equipped with a type F, interlocking, 
F-70-B-HT-E coupler. It had a lightweight of 85,300 pounds, a capacity 
of 236,000 pounds, and at the time of accident, a gross weight of 237,674 
pounds. The tank car was equipped with a safety valve set to relieve 
internal pressure when the pressure exceeded 280.5 pounds. 

In addition to the 22-inch by 26-inch puncture, the running board, 
handrail, airbrake equipment, handbrake mechanism, and coupler on the 
east end of the car were damaged. The east end of the car was also 
burned. (See Figure 5.) 

Intact marks on the coupler of the tank car indicated that the coupler 
met the coupler on the boxcar at inpact and subsequently was overridden 
by the boxcar coupler. 

GATX 41623 coirplied with the requirements of 49 CFR 173, 174, and 
179. It was not equipped with head shields or top and bottom shelf 
couplers, nor were they required. 

N&W 49203 — N&W 49203 was a 40-ton, 40-foot, steel boxcar with wood 
flooring and lining. Its lightweight was 44,000 pounds with a load limit 
of 98,000 pounds. The car was equipped with cast iron brakeshoes, an 
Ajax AAR 1942 handbrake, friction bearings, and type E couplers. 

The west end of the car was caved in, and the carrier iron and por- 
tions of the striker casting below the carrier iron were damaged by im- 
pact. The severe damage to the knuckle and other impact scars confirmed 
that the couplers met at inpact and that the boxcar coupler bypassed 
over the tank car coupler. The car was also damaged by fire. 

Other Cars of Hazardous Materials — The other four tank cars coupled 
to GATX 41623 were either DOT Specification 112A or 114A, 30,000 gallon 



- 10 - 




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tank cars loaded with isobutane. The five-car cut of tank cars had a 
gross weight of about 1,169,000 pounds. 

In addition to the five tank cars of isobutane, there were seven 
cars of hazardous naterials at various locations in the yard at the time 
of the explosion. Except for GATX 41623, none of the cars of hazardous 
materials were seriously damaged. 

Emergency and Rescue 

Designated railroad offices called local emergency rescue and police 
services. Intrayard communications were limited severely by damages to 
the electrical power supply and intercom and speaker systems. 

Fire was difficult to control because there were no fire hydrants in 
the yard and firemen had to pull fire hoses long distances. 

Although there was no emergency plan, en^loyee volunteers moved 
hazardous materials, including one car of explosives, out of the affected 
area. The injured were taken to nearby hospitals. 

N&W Operating Controls 

On July 26, 1974, the N&W issued a General Notice which said that 
cars bearing a "DANGEROUS" placard would henceforth be handled as a Class 
"A" explosive in switching operations. (See Appendix B.) The current 
instructions for handling Class "A" explosives were reissued, widely dis- 
seminated, and posted. 

Tests 

At the Safety Board's request, the NScW conducted a series of roll- 
ability tests to determine how similar cars and randomly selected cars 
would roll on track 11. A five-car cut of loaded tank cars, similar to 
those in the accident, was released at speeds varying from 1 to 6 mph. 
When released at 3 laph, the cut accelerated to 8.4 nph 2,609 feet east 
of the track 11 switch. In every case, the speed of the cut of cars in- 
creased after release. 

In tests made by the Railway Progress Institute and the Association 
of American Railroads (RPI-AAR) Railroad Tank Car Safety Research and Test 
project, a string of secured cars was inpacted by a heavy ram car with a coupler 
mounted so that it struck the tank head directly in the middle. In order to 
puncture the tank head of a car like the one at Decatur, a speed of 12.7 
n^jh was required. Technical witnesses who were familiar with the RPI-AAR 
tests and with the puncture at Decatur estimated that the latter puncture 
could not have been made at an impact speed of less than 15 laph. 



- 12 - 



Regulatory Activity 

The Administrator, Federal Railroad Administration, on August 9, 
1974, published a Notice of Proposed Rulemaking to amend 49 CFR 174,589 
to prohibit the switching of all freight cars placarded "DANGEROUS" un- 
less coupled to a locomotive and to prohibit free-rolling cars from 
coupling to those placarded cars. (See Appendix C.) 

The Illinois Commerce Commission on August 8, 1974, issued an interim 
order. General Order No. 200, which required special handling of placarded 
cars in a shove-to-rest switching operation. Railroads in Illinois, ex- 
cept the NScW, obtained an injunction to forestall its inqjlementation. 
(See Appendix D.) 

After a similar tank car accident in the Southern Pacific's Engle- 
wood Yard at Houston, Texas, on Septeiriber 21, 1974, the Safety Board on 
October 11, 1974, recommended that FRA invoke its emergency powers "to 
prohibit switching of tank cars containing coit^ressed flammable gases un- 
less the tank cars are under the control of a locomotive and prohibit such 
tank cars from being coupled by other free-rolling equipment." The Safety 
Board further recommended that the FRA "... issue a list of the compressed 
flammable gases that are normally shown on waybills." (See Appendix E.) 

On October 25, 1974, FRA issued Emergency Order No. 5, which requires 
a "shove-to-rest" switching of DOT Specification 112A and 114A tank cars 
loaded with con^jressed flammable gas. (See Appendix F.) 

On July 23, 1974, the FRA issued an amendment to 49 CFR 173 and 179. 
The amendment established the requirement for protective head shields on 
D0T-112A and -114Atank cars after August 31, 1974. Industry has until 
December 31, 1977, to bring these designated tank cars into conformance. 

The FRA regulations require that noneirployees' injuries as a result of 
an event arising from the operation of a railroad be reported if the in- 
jury results in; 

1) Death of ai^ person from an injury within 365 days of the 
incident . 

2) Injury to one or more persons that requires medical treatment. 

Effective January 1, 1975, the form for reporting such injuries is 
FRA form F-6180.55. 

In addition to the foregoing report used by the railroads, all 
Common Carriers are required to report to the Department of Transporta- 
tion on form DOT F-5800.1 accidents that involve the unintentional 
release of hazardous materials. 



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Neither of these reports deals specifically with the nature of the 
injury, the cost or extent of the damage, the danger range of the hazard- 
ous material, nor other relevant data. 

ANALYSIS 

The Accident 

The marks on the coupler of the punctured tank car and on the coupler 
of the empty boxcar clearly indicate that the two couplers engaged at 
first intact. To puncture the tank, the boxcar coupler had to disengage 
vertically, override the coupler of the tank car, and strike the head of 
the tank with sufficient force. The broken carrier iron on the boxcar 
indicates that an initial downward movement of that coupler, then a re- 
bound upward, caused the vertical separation. That action is consistent 
with what one would expect when an unusually heavy cut of large tank cars 
moving at excessive speed atteiiq)ts to couple to a free-standing light 
boxcar . 

The shape and size of the puncture indicates that it was made by the 
coupler of the enqjty boxcar. Although the speed of the iiipact is not 
known, in order to disengage the coupler vertically and maintain enough 
momentum to puncture the tank, an inqjact speed greater than that which 
the cut of cars could have attained if they had been released at 3 to 4 
mph would be required. To attain a speed of 10 n^h at inpact, a five- 
car cut of tank cars similar to the cut in this accident was released at 
6 iiq)h. 

Several other factors may have combined to cause the overspeed 
switching: (1) The switchmen had not been instructed about the speed re- 
quirements for switching cars, and they did not understand the rolling 
characteristics of various cars on that track. (2) It appears that super- 
visors had not en^hasized to the switchmen the risks of overspeed cou- 
plings. (3) The acceptance by supervisors of routine overspeed damage in 
switching often leads to conteiiq)t for good switching requirements by the 
switchmen. 

The switchmen's lack of understanding about the risks of switching 
hazardous materials resulted from incomplete training and failxire on the 
part of supervisors to disseminate the infortiation developed by N&W 
management. Management's failure to disseminate information about similar 
accidents at other railroads may have contributed to the switchmen's lack 
of understanding of the risks. 

Losses Attributable to Hazardous Materials 

Currently, there is no feasible emergency action to control these 
hazardous materials after they escape from the tank cars. In the absence 



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of such action, safety regulations should seek to limit the size of the 
potential losses. Currently, regulations do not address this principle 
for bulk tank car shipments. 

The Safety Board is aware of two other cases in railroad yards since 
1972 1/ and one other case outside the railroad environment 2/ in which 
mixtures of escaping liquefied petroleum gas and air exploded or deto- 
nated. 

The Dormitory Location 

All of the enployees who were fatally burned were outside the dormi- 
tory and most of those seriously injured were inside or in the vicinity 
of the dormitory. The location of the dormitory subjected those persons 
to known hazards. Since the explosion, N&W has arranged for dormitory 
services outside the yard. 

Postaccident Emergency Plan 

After the explosion, some employees assisted the injured and helped 
to move cars of hazardous materials to a safer location. A documented 
emergency plan with which all employees were familiar would have appor- 
tioned and assigned responsibilities for emergency activities. 

Fire damage was more extensive than it would have been if there had 
been a fire hydrant system in the yard or other preplanned procedure for 
obtaining water. 

Puncture of Tank Heads in Switching Accidents 

Logically, the puncture of tank cars by couplers can be prevented by 
preventing the couplers from disengaging. Before the accident at Decatur, 
it was known that couplers will puncture tank heads under certain over- 
speed circumstances. Equipping tank cars with top and bottom shelf cou- 
plers might prevent most disengagements which result from overspeed 
switching impacts and other overstressing of the couplers. Also it was 
known that a significant number of those punctures could be prevented by 
a head shield. 

Currently 49 CFR 179.14 requires that tank cars be equipped with 
interlocking couplers (type F) . Interlocking couplers only resist disen- 
gagement in both directions when they are mated with another interlocking 
coupler. However, the top and bottom shelf coupler resists disengagement 
when mated with standard type E or interlocking couplers. 

T7 A&S Gateway Yard, East St. Louis, 111., January 22, 1972, NTSB Report 
Number OTSB-RAR-73-1, and S.P. Englewood Yard, Houston, Texas, 
September 19, 1974. Report not released. 

2/ Phillips Pipe Line Co. Propane Case Explosion, Franklin County, 
Missouri, December 9, 1970. NTSB Report Number NTSB-PAR-72-1. 



- 15 - 



The capability of the top and bottom shelf coupler on tank cars 
should be determined by controlled tests. Tests are necessary to deter- 
mine if the couplers can resist disengagement in accidents and to deter- 
mine if there is a need or justification for their use in conjunction 
with head shields. Therefore, the Safety Board believes that the perform- 
ance of the top and bottom shelf E coupler has not been analyzed suffi- 
ciently and that further study is needed. 

Since the accident at Decatur, Illinois, FRA regulations now require 
that DOT specification 112A and 114A tank cars be equipped with head 
shields. The Safety Board also believes that continuing tests and close 
in-service surveillance of head shields are needed to determine if the 
industry-alleged problems with stress and fatigue on the tank car stub- 
sill actually exist. 

In the meantime, FRA Emergency Order No. 5 will lower significantly 
the probability of a tank head puncture by a coupler during switching. 

Damage and Casualty Reports 

The FRA testified that it atten^jts to relate the degree of protec- 
tion in its regulations for specific commodities to the degree of severity 
of accidents likely to occur in transportation. 

In order to implement this approach, the effects of hazardous mate- 
rial releases in accidents must be predicted. Such predictions depend 
on factors such as the size of the danger zone, dispers n characteris- 
tics of the hazardous materials, dangers to persons and properties, and 
other variables. Without experimental data, the best source of these 
data is hazardous materials accidents which involve hazardous materials 
for which regulations are being considered. 

The Safety Board pointed out in its report of the Alton and Southern 
accident at East St. Louis, Illinois, 3/ that there is a need to identify 
and document the principal loss-producing mechanism encountered in hazard- 
ous materials transportation accidents. This documentation should also 
identify the danger zone in which injuries occur. A recommendation to 
resolve this need was made to the FRA in that accident report. 

Current reporting forms F-6180.55 and DOT F-5800.1, which are used by 
the railroads, do not require the reporting of accident data which would 
support the desired predictions. This results in an inadequate data base by 
which a regulatory agency can determine the needed protection. 



_3/ Railroad Accident Report nioiriber NTSB-RAR-73-1, Hazardous Materials 
Railroad Accident in the Alton and Southern Gateway Yard in East 
St. Louis, Illinois, January 22, 1972. 



- 16 - 



Amendment of form F-6180.55 could provide for the reporting of the 
needed data from railroad accidents; however, if form DOT F-5800ol were 
amended, the data for predictions of harm in all transportation modes 
could be developed. 

CONCLUSIONS 

1. The head of tank car GATX 41623 was punctured by the coupler 
of N&W boxcar 49203. 

2. The coupler of N&W 49203 overrode the coupler of GATX 41623 
because of an atten^ted coupling at an undetermined speed 
which was equal to or exceeded 12.7 raph. 

3. The overspeed irpact resulted because switchmen released the 
five-car cut of tank cars at an excessive speed, 

4. The blast resulted from the explosion in open air of vaporized 
isobutane which had escaped from the punctured tank car, GATX 
41623. 

5. The crew that switched the tank cars was not trained and in- 
structed adequately about risks involved in the switching of 
tank cars of flammable conpressed gases. 

6. The N&W did not have a plan or a system that made firefighting 
materials convenient and readily available to combat fires in 
Decatur Yard. 

7. Head shields or top and bottom shelf couplers on GATX 41623 
might have prevented the puncture of the tank head; however, 
head shields and top and bottom shelf couplers cannot be relied 
upon to eliminate con^letely all tank car punctures . 

8. Requirements for limiting losses when the heads of tank cars 
containing hazardous materials are punctured need to be con- 
sidered in the regulations . 

9. GATX 41623, its lading, and its handling con^lied with require- 
ments of Federal Regulations and railroad interchange rules. 

10. Reporting requirements for DOT form F-5800.1 need to be 
amended to provide information to support implementation of the 
regulatory approach that the degree of protection should reflect 
the degree of severity in hazardous materials accidents. 

11. Federal requirements for reporting railroad accidents which in- 
volve hazardous materials distort intermodal safety conparisons 



- 17 - 



and do not require sufficient information to assess accurately 
the hazards to the public from various materials. 

PROBABLE CAUSE 

The National Transportation Safety Board determines that the prob- 
able cause of the accident was the overspeed impact between the heavy cut 
of tank cars and the uncoupled light boxcar, which resulted from the re- 
lease of the tank cars at a higher- than-acceptable switching speed. The 
lack of written guidelines to assist the switchman in determining the 
proper switching speed contributed to the accident. The crewmembers' 
lack of understanding of the risks involved in switching hazardous mate- 
rials also was a contributing factor. 

RECOMMENDATIONS 

The National Transportation Safety Board recommends: 

That the Federal Railroad Administration, in cooperation with the Railway 
Progress Institute and the Association of American Railroads: 

(1) Promulgate regulations to limit losses in accidents involving 
the transportation of bulk hazardous materials by rail. 
(Recommendation No. R-75-18) 

(2) Determine the capabilities of top and bottom shelf couplers, 
head shields, and a combination of both, and issue regulations 
to require that D0T-112A and -114A tank cars be equipped with 
the best practical combination. (Recommendation No. R- 75-19) 

That the Norfolk and Western Railway Company: 

(3) Insure that the yard en^loyees and their supervisors who are 
involved in the handling of hazardous materials are cognizant 
of the risks involved in switching hazardous materials and re- 
quire switchmen to switch cars of hazardous materials accord- 
ingly. (Recommendation No. R- 75-20) 

(4) Establish a plan for combatting emergencies in Decatur Yard such 
as the one on July 19, 1974, which should include an adequate 
fire control system. (Recommendation No. R- 75-21) 

That the Secretary of Transportation: 



(5) Revise form F-5800.1 to obtain information required to support 
the rulemaking approach so that the degree of protection re- 
flects the degree of severity of specific commodities in acci- 
dents. Such changes should address at least the delineation of 
the danger zone, and types and degree of injury or damages ex- 



- 18 - 



perienced by the various kinds of parties at risk. (Recom- 
mendation No. R-75-22) 

The Safety Board reiterates and reemphasizes the iuqjortance of the 
following recommendation made in previous accident reports. The recom- 
mendation has not been iiq)lemented fully and is applicable to this acci- 
dent; 

Railroad Accident Report, Hazardous Materials Accident in the Alton 
and Southern Gateway Yard in East St. Louis, Illinois, January 22, 1972: 

"4. The Federal Railroad Administration review and, if necessary, 
revise its reporting requirements for accidents involving 
hazardous materials to obtain more accurate reporting of 
casualties adjacent to railroad premises. (Recommendation No. 
R-73-4)." 

BY THE NATIONAL TRANSPCSITATION SAFETY BOARD 

/s/ JOHN H. REED 



Chairman 



/s/ FRANCIS Ho McADAMS 



Member 



/s/ LOUIS M. THAYER 



Meii±)er 



/s/ ISABEL A. BURGESS 



Menfcer 



/s/ WILLIAM R. HALEY 
Member 



April 10, 1975 



- 19 - 



APPENDIX A 
Cut Slip For Assignment No. 1 



Initial 


Number 


Kind 


AESX 


8384 


T 


AESX 


10839 


T 


AESX 


10813 


T 


NW 


161537 


B 


NW 


49203 


B 


PFE 


459293 


N 


PFE 


456020 


N 


PSPX 


33785 


T 



PSPX 
PSPX 
PSPX 

GATX 

NATX 
AESX 
AESX 
AESX 
AESX 
ITC 



33796 

33559 

32020 

41623 

22325 
8401 
8342 
904 
8209 
8431 



Track 

4 9 711UP SYRUP EMERY 

30 9 711KCS SYRUP WOLF 

30 9 711BN SUGAR INDU 

4 9 711UP FLOUR KRUSTE 

11 9310NW ACT 

10 9711UP ACT 

10 9711UP AGT 

11 9310TRR LPGAS PHILL 

11 9310TRR LPGAS PHILL 

11 9310TRR LPGAS PHILL 

11 9310TRR LPGAS PHILL 

11 9310TRR LPGAS PHILL 



9179NW CNOIL 
9711NP SBOIL 
9 711NP SYRUP 
9179NW SYRUP 
9 711ATS SBOIL 
9711UP FEED 



ANDER 

DOUBLE 

EMERY 

CARNA 

STAR 

CHIN 



TR EMERYVIl 

BKG SHREVE7 

TFR SEATTLE 

D SEATTLE 

STLOUIS 

KANCIT8 

KANCIT8 

PE ESTLOUI 
DANGER6 

PE ESTLOUI 
DANGER6 

PE ESTLOUI 
DANGER6 

PE ESTLOUI 
DANGER6 

PE ESTLOUI 
DANGER6 

CL JACKSOV 

D CTYOFIN 

TR EMERYVI 

TI JACKSOV 

KIS TERMISL 

GRA CHINO 



- 20 - 

APPENDIX B 

NORFOLK AND WESTERN RA.ILWAY COMPANY 

GENERAL NOTICE 

SPECIAL INSTRUCTIONS FOR THE HANDLING OF 

CERTAIN CLASSIFICATIONS OF "DANGEROUS" TANK CARS 

EFFECTIVE IMMEDIATELY, LOADED TANK CARS PLACARDED "DANGEROUS" WHICH FALL 
IN THE FOLLOWING HAZARDOUS MATERIALS CLASSIFICATION AS INDICATED IN THE 
"DESCRIPTION OF ARTICLES" SECTION OF THE WAYBILL WILL BE DESIGNATED AS 
CLASS "A" DANGEROUS AND HANDLED IN SWITCHING OPERATIONS . IN ALL YARDS 
AND ON LINE OF ROAD IN THE SAME MANNER AS ARE CARS CONTAINING CLASS "A" 
EXPLOSIVES; THAT IS, THEY WILL ONLY BE MOVED WITH LOCOMOTIVE ATTACHED, 
ALSO, NO OTHER CAR ROLLING FREE WILL BE ALLOWED TO COUPLE TO ANY SUCH CAR, 
BUT MUST ONLY BE MOVED WITH LOCOMOTIVES, AND ALL COUPLINGS WILL BE MADE 
WITH NO MORE FORCE THAN IS NECESSARY TO COMPLETE THE COUPLING: 

FLAMMABLE COMPRESSED GAS 

FLAMMABLE POISON GAS - HYDRO CYANIC ACID (HCN) 

POISON GAS OR LIQUID - CLASS "A" 
ANY "DANGEROUS" PLACARDED TANK CAR FALLING IN ANY OTHER HAZARDOUS MATE- 
RIALS CLASSIFICATION SHOULD BE HANDLED IN ACCORDANCE WITH EXISTING RULES. 

/s/ R. F. Dunlap 
SENIOR VICE PRESIDENT-OPERATIONS 
ROANOKE, VIRGINIA 
July 26, 1974 



21 - 




APPENDIX C 

DEPARTMENT OF TRANSPORTATION 
HAZARDOUS MATERIALS REGULATIONS BOARD 

WASHINGTON, DC. 20590 



29197 



^^Amo^'- 



r49CFRPart 174] 

(Docket No. HM-120; Notice No. 74-H] 

FREIGHT CARS 
Switching of Placarded "Dangerous" 
The Hazardous Materials Regulations 
Board is considering amendment of 
: 174.589, of Title 49 Code of Federal 
Regulations, which prescribes the re- 
quirements for handling placarded 
freight cars carrying hazardous mate- 
rials. 

As a result of preliminary findings con- 
cerning the catastrophic tank car explo- 
sions at Decatur. Illinois, on July 19 
1974, and Wenatchee, Washington, on 
August 6, 1974, the Board believes that 
§ 174,589 should be amended to prevent 
further occurrences. Although the Na- 
tional Transportation Safety Board has 
not yet completed its Investigation of 
these accidents nor determined their 
probable cause, it appears that the De- 
catur accident may have occurred as a 
result of rough handling and that rough 
handling of freight cars placarded 
'Dangerous" during switching operations 
may have contributed to the Wenatchee 
accident. 

The proposed changes In § 174.589 are 
described below: 

Paragraph (c). It Is proposed to ex- 
pand the provisions of this section to 
Include freight cars placarded "Danger- 
ous." This would prohibit the uncou- 
pling or cutting off of these cars while 
they are in motion, the striking of these 
cars by other cars moving under their own 
motion, and the coupling of these cars 
with more force than is necessary to 
complete the coupling but in no case at 
a speed of more than 4 m.p.h. 

Paragraph (d) . It is proposed to delete 
this paragraph as surplusage since all 
freight cars placarded "Dangerous" 
would be required to be handled In ac- 
cordance with the provision of para- 
graph (c). 

Pursuant to the provisions of section 
102(2) (c) of the National Environmen- 
tal Policy Act (42 USC 4321, et seq.) , the 
Board has considered the requirements 
of that Act concerning Environmental 
Impact Statements and has determined 
that the amendments proposed in this 
notice would not have a significant im- 
pact on the quality of human environ- 
ment within the meaning of that Act. 
Accordingly, an Environmental Impact 
Statement Is not necessary and will not 
be issued with respect to the proposed 
amendments. 

In consideration of the foregoing, it is 
proposed to amend 49 CFR Part 174 as 
follows: 

In § 174.589, paragraph (c) would be 
revised; paragraph (d) would be de- 
leted; paragraphs (e) through (n) would 
be redesignated paragraphs (d) through 
(m) respectively as follows: 



§ 174.589 Handling care. 

(c) Switching of Placarded Cars. A 
car placarded "Dangerous", "Explo- 
sives", 'Tolson Gas", or "Flammable 
Poison Gas", or any flat car carrying a 
trailer placarded "Explosives", "Poison 
Gas", "Dangerous", or "Dangerous- 
Ra'dioactive Material" shall not be cut 
off while in motion. No car moving under 
its own motion shall be allowed to strike 
any car placarded "Dangerous", "Explo- 
sives", "Poison Gas", or "Flammable 
Poison Gas", or any flat car carrying a 
trailer placarded "Explosives", "Poison 
Gas", "Dangerous", or "Dangerous- 
Radioactive Material" nor shall any such 
car be coupled into with more force than 
Is necessary to complete the coupling 
but In no case at a speed of more than 
4 m.p.h. 

(1) When transporting a car placarded 
"Explosives" in terminals, yard, side 
tracks, or sidings such cars shall be sepa- 
rated from the engine by at least one 
nonplacafded car. 

(2) CHosed cars placarded "Explosives" 
shall have doors closed before they are 
moved. 

(d) [Deleted] 

Interested persons are invited to pre- 
sent their views on these proposals. 
Communications should identify the 
dtx;ket number and be submitted in 
triplicate to the Secretary, Hazardous 
Materials Regulations Board, Depart- 
ment of Transportation, Washington, 
D.C. 20590. Communications received on 
or before September 20, 1974, will be 
considered before final action is taken 
on these proposals. All comments re- 
ceived will be available for examination 
by interested persons at the Office of the 
Secretary, Hazardous Materials Regula- 
tions Board, Room 6215, Trans Point 
Building, Second and V Streets, SW., 
Washington, D.C. both before and after 
the closing date for comments. The pro- 
posals contained in this notice may be 
changed in light of the comments re- 
ceived. It is contemplated, due^ to the 
serious potential of danger In the han- 
dling of cars placarded "Dangerous", that 
a final rule in this proceeding may be 
effective in less than 30 days from the 
date of Its publication in the Federal 
Register. 

Authoritt: Transportation of Eiqjlosives Act 
(18 tJ.S.C. 831-835) section 6 of the Depart- 
ment of Transportation Act (49 U.S.C. 1655). 

Issued in Washington, D.C, on Au- 
gust 9, 1974. 

John W. Ingram, 
Federal Railroad Administrator 
Member, Hazardous Materials 
Regulations Board. 
(PR Doc.74-18750 Piled 8-13-74;8:45 am] 



FEDERAL REGISTER, VOL 39, NO. 158 — WEDNESDAY, AUGUST 14, 1974 



- 22 - 



APPENDIX D 



STATE OF ILLINOIS 
ILLINOIS COMMERCE COMMISSION 



Illinois Commerce Commission, 
on its own motion, 



General Order 200 



Hazardous materials regulations. 

INTERIM ORDER 

By the Commission: 

WHEREAS, by Section 57 and other provisions of the Public Utilities 
Act this Commission has authority to promulgate rules prescribing safety 
devices and appliances to be utilized by public utilities and to require 
the safe operation by public utilities of their plant and equipment, and 

WHEREAS, there has been an increase in this State and elsewhere of 
incidents involving the carriage and handling of hazardous materials, and 

WHEREAS, those incidents have resulted in substantial property damage 
and in injuries and loss of life, and 

WHEREAS, there are indications that the causes of those incidents have 
included not only track failures, concerning which this Commission has 
pending other appropriate proceedings, but also equipment defects and in- 
adequate operating practices, and 

WHEREAS, Class A explosives and poisonous gases have been subjected 
to special railroad handling procedures as specified in R. M. Graziano's 
Tariff No. 27, 111. C.C. No. 3, and experience indicates that other 
materials listed in that tariff as hazardous are similarly dangerous and, 
therefore, all materials required by that tariff to be placarded should 
be subjected to special handling and inspection procedures as hereinafter 
set forth, and 

WHEREAS, the Commission finds that a hearing should be scheduled, 
at which to receive the views of interested persons and organizations 
with respect to such regulations, but further the Commission finds that 
there exists a state of urgency which requires that regulations as here- 
inafter set forth should be adopted on an interim basis. 

IT IS THEREFORE ORDERED upon the Commission's own motion, subject 
to its power of modification, alteration and withdrawal, that the hazard- 
ous materials regulations attached hereto as Appendix "A" be, and the 



- 23 - 



APPENDIX D 

same are hereby, adopted, to be effective upon service of copies of said 
regulations upon the designated agents of railroad public utilities. 

IT IS FURTHER ORDERED that a hearing be scheduled for 11:00 a.m., 
on August 26, 1974, at the Commission's offices in Springfield, at which 
time the Commission's staff, railroad public utilities and other inter- 
ested persons and organizations shall be provided the opportunity to 
offer evidence, comments and recommendations with respect to the regula- 
tions attached hereto as Appendix "A" as well as to offer for the Com- 
mission's consideration any other proposed regulations pertaining to the 
carriage and handling of mazardous materials. 

By order of the Commission this 8th day of August, 1974. 

(SIGNED) MARVIN S. LIEBERMAN 

Chairman 

(SEAL) 

WSC/kl 



- 24 - 

APPENDIX D 

HAZARDOUS MATERIALS REGULATIONS 

Reference hereinafter to "placarded cars" shall mean and include all 
cars bearing placards placed thereon according to the requirements for 
shipping hazardous materials as set forth in R. M. Graziano's Tariff No. 
27, 111. C.C. No. 3, or supplements thereto or successive issues thereof. 

1. No placarded cars shall be released to roll free on any track. Nor 
shall any cars be released to roll free on any track on which a 
placarded car is standing. When cars are switched under these con- 
ditions, they shall remain coupled to motive power until brought to 
a conplete stop. 

2. When a switch list is given to a switching crew, placarded cars 
shall be plainly indicated in such a manner that the crew can 
follow the above special procedures. 

3. These requirements shall also apply to trains on the road which are re- 
quired to perform switching operations at intermediate stops. 

4. When placarded cars arrive in a yard, the yard master shall notify 
all switching en^loyees on duty at that time of the presence of 
these cars, warning them to watch for the placard indicating the 
presence of hazardous material so that all special handline proce- 
dures are followed. This shall not apply to through trains not to 
be switched. 

5. Whenever the movement known as "feeling for a joint" is undertaken 
with cuts of cars containing placarded cars, it shall be required 
that a trainman ride the car at the head of one of the cuts of cars 
to communicate by radio with each engine to advise of the proximity 
of the opposing cuts so that a smooth and easy coupling can be 
accocplished . 

6. Placarded cars, as they arrive in a yard, shall be thoroughly in- 
spected by an experienced car inspector for any and all defects as 
to car structure and components and a record of such inspection shall 
immediately be made and filed with the yard master. No placarded car 
shall be moved until such inspection shows the car to be free of 
defects. Any car found to have a defect shall have necessary repairs 
made immediately. If such repairs would endanger the repair area, 
the hazardous materials shall first be removed from the defective 
car and such other precautions taken as will permit safe repair or 
removal. In the event of leakage, the car shall be further segre- 
gated and removed as far as practical from any others and explosive 
experts called to the scene immediately to take charge of further 
repairs and handling. 

APPENDIX "A" 
Page 1 



- 25 - 



APPENDIX D 

7. No through movements of placarded cars shall be moved over mainline 
tracks that do not qualify as class 3 tracks or better by FRA. 
standards.* 

8. No placarded cars shall be handled on passing-sidings where said 
tracks do not qualify as class 2 or better by FRA standards.* 

9. No placarded cars shall be handled on tracks in yards where said 
tracks do not qualify as class 1 or better by FRA standards.* 

10. A system of routing shall be inplemented whereby placarded cars 
which will travel any substantial distance within the State of 
Illinois will be routed along the safest possible route through the 
State. The safest route shall be determined by considering: 

(1) The FRA classification of the tracks, over which the 
car is to be operated, 

(2) The proximity of the route to population centers, and 

(3) Routing the car over the lines which would require 
the fewest switching and interchange movements. 

11. All railroads shall implement a safety program which would acquaint 
their operating personnel with the danger involved in the handling 
of cars containing hazardous material. This program shall include 
instruction on recognition of hazardous material placards used, and 
the precautions to be followed in handling of cars in accordance 
with the placard and the foregoing requirements. 



FRA Classes of Track 

Class 1 

Class 2 

Class 3 

Class 4 

Class 5 

Class 6 



Freight Train 


Operating Speeds 


10 


mph 


25 


n^jh 


40 


mph 


60 


n^h 


80 


nph 


110 


iiq>h 



APPENDIX "A" 
Page 2 



- 26 - 



NATIONAL TRANSPORTATION SAFETY BOARD 

WASHINGTON, D.C 



APPENDIX E 



ISSUED: October 11, I974 



Forwarded to: 

Honorable John W. Ingram 

Administrator 

Federal Railroad Administration 

Washington, D. C, 20590 



SAFETY RECOMMENDATION (Si 
R. 74-29 & 30 



On July 19, 1974, a tank car was punctured during switching 
operations in the Norfolk and Western Yard at Decatur, Illinois. 
On September 21, 1974, a tank car was similarly punctured during 
switching operations in the Southern Pacific Englewood Yard, 
near Houston, Texas. Both tank cars contained heavier -than- air 
compressed flammable gases, which, as a result of the punctures, 
leaked and exploded. Several persons were killed and many- 
were injured. 

On January 22, 1972, a similar accident occurred in the 
Alton and Southern Gateway Yard in East St. Louis, Illinois. 
Each of these accidents produced injury and damage well beyond 
the confines of railroad property. 

Following the 1972 accident at East St. Louis, the Safety 
Board recommended that: 

"The Federal Railroad Administration establish a 
requirement that railroad carriers handle switch- 
ing operations of cars containing large shipments 
of hazardous material, with a danger range beyond 
railroad property boundaries, in the same manner 
as they handle switching operations of cars contain- 
ing explosives, " (Recommendation No, R-73-2. ) 

There had been no similar accident on record, and only 
one occurrence of the explosion of liquefied petroleum gas by 
detonation in open air. The Board, however, considered that 



- 11 - 



APPENDIX E 

this accident demonstrated the possible results from the 
release of hazardous material having a danger range far 
beyond the boundaries of railroad property, and that pre- 
cautions should be taken to prevent errors in switching from 
impinging upon the community. The background of the recom- 
mendation in the report showed that "minor accidents" were 
being tolerated in many instances in railyards and that a 
small percentage of cars were being subjected to switchyard 
impact above 10 mph. 

The FRA reply said essentially that a wide range of 
materials would have to be included under a recommendation 
designed to confine damage to the railroad property, and gave 
the opinion that it would be more cost-beneficial to prevent 
overspeed impacts in all railroad hump yards than to require 
controlled movements on the subject cars by locomotive. 

The accident at Decatur, Illinois, on July 19, 1974, 
demonstrated that detonation of LPG gas in open air, following 
a switching accident, could recur. This accident involved 
switching in a flatyard rather than humping operations, and 
also involved free- rolling cars. Improvements to humping 
could not have prevented this accident. 

The Hazardous Materials Regulations Board, over 
signature of the Administrator, FRA, on August 9, 1974, 
issued a Notice of Proposed Rulemaking which would imple- 
ment the Board's 1973 recommendation that evolved from the 
East St. Louis accident. The proposal also mentioned an 
accident at Wenatchee, Washington, on August 6, 1974, which 
is currently being investigated by the Safety Board. In that 
accident a large scale explosion occurred with effects far 
beyond the railroad yard. It is not yet determined whether 
the Wenatchee accident involved switching. 

The FRA proposal would in effect, prohibit switching of 
all freight cars placarded "dangerous, " without a locomotive 
attached, and would prohibit the same placarded cars from 
being coupled by free-rolling car impact during switching. 
This proposal contemplates essentially the same scope of 
definition of hazardous materials which was described by the 
FRA in its earlier reply to the Board's initial recommendation. 



- 28 - 



APPENDIX E 

While this notice (Docket No. HM-120; Notice No. 74-11) 
was still open for comment, the accident occurred at the 
Englewood Yard at Houston. This accident involved the same 
detonation- in- open- air explosion mechanism as in the acci- 
dents at Decatur and East St. Louis, Illinois. It also 
involved a puncture in the head of a tank car by an opposing 
coupler similar to those found in the Decatur and East St. 
Louis accidents. The cars involved had been humped, as at 
East St. Louis. 

Whereas the Board's original recommendation sought to 
cover the full range of disastrous effects on the community 
which might arise from free switching of large quantities of 
any hazardous material, the Decatur and Houston accidents 
have drawn attention more specifically to the escape of heavier- 
than-air compressed flammable gases. The occurrence of open 
air detonation of such gases in a railroad yard environment, 
thought to be unique in 1972, is now considered to be a proba- 
bility. As the East St. Louis accident report pointed out, the 
mechanism by which the normally expected fiashfire becomes 
an explosive detonation is as yet unknown. The compressed 
gases released in the three accidents were not the same, 
propylene having been released at East St. Louis, isobutane 
at Decatur, Illinois, and butadiene at Houston. Nevertheless, 
all three cases exhibited the phenomenon of open air detonation 
in a railroad yard. Although the three accidents carry no sta- 
tistical significance a question is now raised as to whether 
there is some undetected reason for such detonations to occur 
in railroad yards. 

The Safety Board believes that since these three 
accidents involved compressed flammable gases, the final FRA 
rule should include this category of hazardous materials. The 
later accidents have not only increased the predictability of a 
recurrence, but have also focused attention on compresed 
flammable gases in free-rolling switching operations. There- 
fore, the problem of detonation of compressed flammable 
gaees must be dealt with at this time, to prevent recurrence 
of this type of accident. 

The time allowed to respond to the NPRM has been 
extended 30 days beyond the original date of September 20, 1974. 



- 29 - 



APPENDIX E 

Consequently, at least 30 days will pass before any action 
will be taken to prevent recurrences. 

The Safety Board believes that prompt action is 
required and that the emergency powers provided to FRA 
under the Federal Railroad Safety Act of 1970 were intended 
to cover such new situations. These emergency powers 
should be employed to prevent tank cars containing com- 
pressed flammable gases from rolling-free during switch- 
ing operations or from being struck by or coupled to other 
free-rolling cars. 

In view of the above, the National Transportation 
Safety Board recommends that the FRA: 

1. Through its emergency powers, issue an 
order to prohibit switching of tank cars 
containing compressed flammable gases 
unless the tank cars are under the control 
of a locomotive and prohibit such tank cars 
from being coupled by other free- rolling 
equipment. 

2. To assure conformance with such an 
order, issue a list of the compressed 
flammable gases that are normally show^n 
on waybills. 

These recommendations are temporary pending the 
adoption of regulations pursuant to Notice 74-11, Docket 
HM-120. 

REED, Chairman, McADAMS, THAYER, and 
BURGESS, Members, concurred in the above recommenda- 
tions. HALEY, Member, did not participate. 



JfA^f/^/^A 



Bylr John H. Reed 
Chairman 



cc: Secretary Brinegar 



30 



APPENDIX F 



Title 49 — Transportation 

CHAPTER M — FEDERAL RAILROAD AD- 
MINISTRATION, DEPARTMENT OF 
TRANSPORTATION 

(PRA E.O. No. 51 

LOADED TANK CARS OF FLAMMABLE 
COMPRESSED GAS 

Emergency Order Restricting Handling 

On August 14, 1974, a notice of pro- 
posed rule making (NPRM) Docket No. 
HM-120; Notice No. 74-11 was published 
in tlie Federal Register requesting com- 
ments on a proposal to restrict the 
handling of all cars placarded dangerous 
(39 PR 29197). The proposed restrictions 
would prohibit the uncoupling or cutting 
off of these cars while they are in motion, 
the striking of these cars by other cars 
moving under their own motion, and the 
coupling of these cars with more force 
than is necessary to complete the cou- 
pling. At the request of commenters the 
date for comment was extended from 
September 20, 1974, to October 22, 1974. 

On September 21, 1974, an accident 
occurred involving the handling of DOT 
112A tank cars transporting Butadiene, 
a flammable compressed gas. This acci- 
dent resulted in one fatality, 66 injuries 
and over ten million dollars in damages. 
On October 11, 1974, the National Trans- 
portation Safety Board (NTSB) issued 
Safety Recommendations R-74-29 and 30 
recommending that FRA issue an emer- 
gency order to prohibit switching of all 
tank cars containing flammable com- 
pressed gas unless the tank cars are 
under control of a locomotive and pro- 
hibit such tank cars from being coupled 
by other free-rolling equipment. In addi- 
tion, the NTSB recommended procedures 
to assure compliance with the order. 

More than forty comments were re- 
ceived in response to the NPRM in HM- 
120. An analysis of the comments indi- 
cated that a large number of commenters 
wanted further study to be made with 
some interim {jrecautionary measures be 
taken with the cars that have caused the 
problems. Several commenters suggested 
PRA take action on the tank cars that 
have been involved in most of the acci- 
dents — the 112A and 114A uninsulated 
tank cars transporting flammable com- 
pressed gas. In addition, commenters 
suggested that tests be conducted to de- 
termine safe coupling speeds and the 
efficiency of hump yard retarders. FRA 
believes that the commenters have raised 
some good points which should be studied 
further before permanent changes are 
made in the regulations. Another NPRM 
will be published soon requesting addi- 
tional comments to assist in determining 
the best practical changes in the regula- 
tions necessary to improve safety. How- 
ever, FRA believes that in the interim, 
special precautions must be taken in 
handling 112A and 114A tank cars. 



PRA has determined that emergency 
action must be taken to prevent more 
catastrophic accidents from occurring. 
Therefore, pursuant to the authority of 
Section 203 of the Federal Railroad 
Safety Act (45 U.S.C. § 432) I am issuing 
the following Order: 

Order 

In addition to the requirements of 
Parts 170-189 of Title 49 of the Code of 
Federal Regulations governing the trans- 
portation of hazardous materials, effec- 
tive 12:01 a.m., October 27, 1974, a rail- 
road may transport flammable com- 
pressed gas in DOT 112A and DOT 114A 
uninsulated tank cars that are not 
equipped with head shields prescribed by 
the Hazardous Materials Regulations 
Board in Docket HM-109, Amendment 
No. 5, 173-83, 179-15 published in the 
July 31, 1974, issue of the Federal 
Register (39 PR 27572), 49 CPR 179.- 
100-23, only under the following con- 
ditions: 

(a) DOT specification tank cars 112A 
and 114A that are not equipped with 
head shields required by 49 CPR 179.100- 
23, transporting flammable compressed 
gas requiring dangerous placards, shall 
not be cut off in motion. No car moving 
under its own momentum shall be al- 
lowed to strike any DOT 112A or 114A 
tank car containing flammable com- 
pressed gas placarded dangerous, that is 
not equipped with head shields required 
by 49 CPR 179.100-23, nor shall any sucli 
car be coupled into with more force than 
is necessary to complete the coupling. 

(b) The shipping papers required by 
49 CPR 174.510 for loaded tank cars 
containing flammable compressed gas 
placarded dangerous must cari-y the no- 
tations: "DOT 112A" or "DOT 114A" and 
"must be handled In accordance with 
FRA E.O. No. 5." 

(c) Railroad employees must be in- 
formed of the presence of these cars and 
instructed to handle them in accordance 
with the requirements of this order. 

A civil penalty 'of not less than $250 
nor more than $2500 will be assessed for 
each violation of this order. 

An opportunity for review of this or- 
der Is provided in accordance with sec- 
tion 554 of Title 5 of the United States 
Code. 

(Sec. 203, 84 Stat. 972, 45 U.S.C. 432; and 
sec. 1.49 (n) of the regulations of the Office of 
the Secretary of Transportation, 49 CFR 
1.49(n)) 

Issued in Washington, D.C. on October 
25, 1974. 

John W. Ingram, 
Administrator. 

[FB Doc.74-25402 Filed 10-29-74:11:25 am] 



FEDERAL REGISTER, VOL. 39, NO. 210 — WEDNESDAY, OCTOBER 30, 1974 



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